1
Migration, Mobility, and Health

OVERVIEW

Opening presentations by Mark Miller of the University of Delaware and Brian Gushulak of the Canadian Immigration Department Health Branch set the context for this workshop by exploring the history and ongoing political and public health significance of human migration and mobility. Their contributions to this chapter establish a firm foundation for those that follow, providing both a wealth of detail and an overarching view of the changing picture of human migration through the ages, and particularly during the recent decades.

Miller’s essay reviews human migratory history, focusing on the contemporary “Age of Migration” that began around 1970. This era “has witnessed major developments in human mobility affecting all areas of the world,” Miller writes. “Understanding this still evolving global migratory context bears importantly upon comprehension of contemporary microbial threats.” Conversely, he notes the importance of health issues to the study of migration and security, particularly in recent years.

Miller examines the geopolitical origins of the present Age of Migration and examines its defining features. These he characterizes as the globalization, acceleration, differentiation, politicization, feminization, and proliferation of migration in the traditional sense (the one-way movement of people from one homeland to another); the advent of formal mechanisms supporting “circular” migrations such as guestworker programs; and the growth of international tourism. Reflecting on the future of migration and development, and recognizing that “the chief threats to U.S. security since the 1970s arose from failed states and the abysmal living conditions of average people in much of the world,” Miller advocates a



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1 Migration, Mobility, and Health OVERVIEW Opening presentations by Mark Miller of the University of Delaware and Brian Gushulak of the Canadian Immigration Department Health Branch set the context for this workshop by exploring the history and ongoing political and public health significance of human migration and mobility. Their contributions to this chapter establish a firm foundation for those that follow, providing both a wealth of detail and an overarching view of the changing picture of human migra- tion through the ages, and particularly during the recent decades. Miller’s essay reviews human migratory history, focusing on the contempo - rary “Age of Migration” that began around 1970. This era “has witnessed major developments in human mobility affecting all areas of the world,” Miller writes. “Understanding this still evolving global migratory context bears importantly upon comprehension of contemporary microbial threats.” Conversely, he notes the importance of health issues to the study of migration and security, particularly in recent years. Miller examines the geopolitical origins of the present Age of Migration and examines its defining features. These he characterizes as the globalization, accel - eration, differentiation, politicization, feminization, and proliferation of migration in the traditional sense (the one-way movement of people from one homeland to another); the advent of formal mechanisms supporting “circular” migrations such as guestworker programs; and the growth of international tourism. Reflect - ing on the future of migration and development, and recognizing that “the chief threats to U.S. security since the 1970s arose from failed states and the abysmal living conditions of average people in much of the world,” Miller advocates a 

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 INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD stronger commitment on the part of the United States to development in Africa, the Middle East, and other developing countries, including increased admissions of permanent residents from these regions. In his subsequent contribution, Gushulak, along with his colleague Douglas MacPherson, of McMaster University and Migration Health Consultants, Inc., presents a comprehensive history of migration-associated disease and disease control policies. The authors characterize “modern migration”—the mechanism that drives Miller’s “Age of Migration”—in terms of its departure from traditional migratory patterns, and explore the challenges it presents for global health, and particularly for the control of infectious diseases. In order to “shift the paradigm” of disease control away from policies focused on geopolitical borders and individual infectious diseases, Gushulak and MacPherson introduce the concept of “population mobility” to replace traditional considerations of migration. “Considering mobility as a global health determinant provides a model upon which we can integrate disease management policies, processes for prevention, knowledge of disparate prevalence environments, and a rigorous health threat to risk assessment ability,” the authors write, and they suggest several approaches to the control of mobility-related disease to support this model. INTERNATIONAL MIGRATION PAST, PRESENT, AND FUTURE1 Mark J. Miller, Ph.D. University of Delaware Public health has been importantly influenced by human mobility patterns since time immemorial. A rich, but frequently overlooked, tradition of scholarship attests to the significance of understanding human mobility for comprehension of events involving plagues and spatial diffusion of illnesses (Diamond, 1997; McNeill, 1977). Many students of world politics and international relations have distinguished themselves by their neglect of health questions in explanations of wars and conquests (Koslowski, 2000). Nevertheless, no effort will be made here to reprise that literature. Rather, the focus will be upon sketching what Stephen Castles3 and I call The Age of Migration, the contemporary migratory epoch that 1This essay builds on a paper prepared for the International Organization for Migration/Center for Migration Studies, Conference on International Migration and Development: Continuing the Dialogue—Legal and Policy Perspectives convened in New York City January 17-18, 2008. That paper was subsequently published in J. Chamie and L. Dall’Oglio, eds. 2008. International Migration and Development. Geneva: ILO and New York: CMS. Pp. 71-78. 2 Emma Smith Morris Professor. 3 Professor of Migration and Refugee Studies, and Director of the International Migration Institute at the University of Oxford.

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 MIGRATION, MOBILITY, AND HEALTH began circa 1970 which has witnessed major developments in human mobility affecting all areas of the world. Understanding this still evolving global migra - tory context bears importantly upon comprehension of contemporary microbial threats. Health issues comprise a not insignificant dimension of the still emerging field of study of migration and security, a scholarly focus of considerable histori - cal pedigree that reemerged after the Cold War and especially after 9/11 (Castles and Miller, 2009). Migrations Past: International Migration in the Modern Age To paraphrase Kemal Karpat,4 rarely does migration not figure importantly in the history of humankind. Recent anthropological evidence concerning the late Iron Age in Europe suggests that distinctive societies were much more interconnected and fluid than once thought (Wells, 2001). The prosperity and goods of ancient Greece and Rome fostered trade and myriad other interac - tions just as the military might of Greece and Rome posed a perceived grave threat to tribes and peoples on the periphery, forcing them to adapt, change, and define their identities. The extensive Viking migrations of the eighth to eleventh centuries gave rise to plunder and violence. But those migrations also involved trade and commerce. Medieval migration of Jews in Europe often was linked to rulers’ efforts to spur economic development and to generate greater tax revenues. Much the same could be said about medieval German migrations eastward (Miller, 2008). The term international migration, which the United Nations (UN) defines as occurring when a citizen or national of one state moves to another state for a period of at least one year, presupposes the existence of an international sys - tem of states. Many students of international relations trace the emergence of the contemporary international or Westphalian system to seventeenth-century Europe and the end of the Thirty Years War5 brought about by the treaties of Westphalia. This embryonic nation-state system then diffused to the rest of the world through processes of colonization and imperialism followed by decoloniza- tion and the embrace of the sovereign national state system born of Europe after World War II. Voyages of discovery, conquest, and trade by Europeans marked the advent of the Modern Age. European domination of the New World ensued as many indigenous people succumbed to European-borne diseases, although Euro- pean populations also were adversely affected by diseases contracted in non- European areas for which Europeans possessed insufficient or little immunity. In general, with the major exception of the 400-year-long African slave trade, which involved over 15 million Africans, population transfers initially were 4 Distinguished Professor of History, Department of History, University of Wisconsin, Madison. 5 1618-1648.

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 INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD quite limited (Curtin, 1997). The cost of maritime travel was prohibitive except for the wealthy and, in an age of Mercantilism, European rulers viewed their subjects as valued possessions, especially for military conscription. The anti - migration norm began to erode only after 1800. A number of developments set the stage for the first era of mass migration, which mainly involved Europeans. The French Revolution gave birth to a new norm, a human right to emigrate. Technological innovations and other factors began to make transatlantic travel economically possible for larger segments of the European population. Many of the former colonies comprising the newly founded American Republic welcomed and encouraged settlement by Europeans. Population growth, particularly in Great Britain and Ireland, which can partially be attributed to improvements in public health, particularly in cities, also consti - tuted a factor. The growth of the Irish population figured centrally. Ireland had been incor- porated into Great Britain in 1801, resulting in growing migration of Irish to England in particular. The poverty of many of the Irish migrants and their Roman Catholicism caused alarm. Soon local governments discovered it was less expen - sive to help transfer the Irish to Canada and the United States than to provide for them in situ. By the 1820s, the mercantilist anti-emigration norm had eroded (Zolberg, 2006). Between 1820 and 1939, roughly 60 million Europeans immigrated to the New World, which included Argentina and other areas in Latin America, Australia, and New Zealand as well as the United States and Canada (Hatton and Williamson, 1998, 2005). However, the composition of the migration flows changed over time, especially after abolishment of serfdom in the Czarist Empire. By the late-nineteenth century, many areas in western and northern Europe had become zones of immigration, particularly France which, in the interwar period, had become the world’s premier land of immigration. In the United States by the 1880s and 1890s, concerns over the effects of immigration had increased. The first federal commission to study immigration, thereby inaugurating migration studies in the United States, suggested reductions in immigration, recommendations that began to be translated into law by 1917. The Quota Acts of 1921 and 19246 severely curtailed European migration to the United States. Other New World immigration lands emulated the United States, thereby bringing the first period of mass migration to a virtual end. After the Great Depression and the long night of World War II, a number of areas reemerged as significant lands of immigration or emigration. The United States admitted several groups of “displaced persons” and continued to admit Mexican temporary workers, which had resumed under a 1942 bilateral accord 6These laws instituted the National Origins system of visa allocation that, as subsequently revised, remained in effect until 1965. The system favored visa applicants of northern European background as opposed to applicants from southern and eastern Europe. See Daniels (2004).

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 MIGRATION, MOBILITY, AND HEALTH with Mexico.7 A major reform of U.S. immigration law in 19528 somewhat reopened the “Golden Door” which had largely been closed in the 1920s. The resumption of immigration policy was accentuated by the 1965 amendments to the 1952 law, which came into effect in 1968 (Daniels, 2004). Hatton and Williamson (2005) have identified five developments that pre - cipitated the Age of Migration by 1970. Latin America changed from being a net importer of international migrants to a net exporter. The bulk of Latin American emigrants went to the United States as Latin American economic growth lagged behind that of the United States. Later, and especially after the Cold War, sig - nificant flows of Latin Americans would also go to Europe, especially to the Iberian Peninsula and Italy. Western Europe itself also became a major zone of immigration, especially after a large faction of post-World War II guestworkers settled, contrary to expectations, and were joined by family members. The oil- producing areas of the Middle East and North Africa also became major zones of immigration. Unlike during the era of mass European emigration to the New World, areas of Asia and Africa also became significant zones of emigration to other areas of the world, but especially to Western Europe and parts of the New World. Finally, somewhat later, the areas of Eastern Europe, long frozen by Soviet domination, itself an echo of the mercantilist antimigration norm, began to thaw. Ostpolitik9 and détente10 began to open the door to emigration. The collapse of Communist governments led to large-scale emigration followed by migration transition; that is, Central and European states simultaneously became lands of emigration and immigration especially after the European Union (EU) enlargements of 2004 and 2007, which brought 12 additional states into the European regional integration framework. The Age of Migration Stephen Castles and I maintain that the current era is defined by six general tendencies: 7The agreement instituted what is termed the second bracero period in U.S. immigration history. Bracero means strong-armed one in Spanish and refers to Mexican workers admitted to the United States to perform temporary services of labor, mainly in agriculture. From 1942 to 1964, there were approximately five million Mexican workers admitted under the accord and subsequent U.S.-Mexican arrangements. 8The Immigration and Nationality Act (INA) of 1952 as amended remains the basis of U.S. immi- gration law today. Its major provisions included retention of the National Origins system of visa allocation and the Texas Proviso, which exempted U.S. employers from prosecution for hiring of aliens ineligible to work in the United States. It passed over President Truman’s veto. 9 German term meaning “eastern policy.” It generally refers to Germany’s normalization of relations with the Eastern bloc countries, including the German Democratic Republic in the early 1970s. 10The relaxation of strained relations, particularly relating to the United States and the Soviet Union.

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 INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD 1. The globalization of migration: the tendency for more and more countries to be crucially affected by migratory movements at the same time (Miller, 2008). 2. The acceleration of migration: international migration is increasing in all the world’s regions. While the percentage of international migrants in the world’s population remains roughly constant at between 2 and 3 percent, the world’s population continues to grow and will do so for several decades into the future, before peaking at about nine billion persons. Most future growth will occur in Africa and Asia. Nevertheless, growth of international migration is not inexorable. Repatriations, for instance, have significantly reduced some refugee populations (Miller, 2008). 3. The differentiation of migration: most countries, states, and governments around the world face increasingly complex challenges in regulating inter- national migration as they encounter, and sometimes precipitate, diverse inflows of migrants (Miller, 2008). Immigration countries tend to receive migrants from a larger number of source countries, so that most immigra - tion lands have entrants from a broad spectrum of social, economic, and cultural backgrounds. 4. The politicization of migration: international migration-related issues are becoming increasingly salient in domestic politics, bilateral and regional relations, and at the global level as witnessed by the creation of the Global Commission on International Migration (GCIM) and the convening of a high-level conference on migration and development at the UN in 2006. After consultation with then UN Secretary-General Kofi Anan in 2003, a number of UN member states funded the GCIM to conduct research, promote dialogue, and make recommendations about policies concerning international migration.11 It mainly stressed the potential benefits of inter- national migration for development. In 2003, the UN General Assembly also decided to hold a high-level dialogue on international migration and development in 2006. The Secretary-General’s report on this meeting recommended a forum for UN member states to discuss migration and development issues further. However, the forum was to be purely advisory and was not intended to facilitate negotiations. The first Global Forum on Migration and Development was hosted by the Belgian government in July 2007, with a second in Manila in October 2008. 5. The feminization of migration: women have become more salient partici- pants in international migration. Many international flows are comprised mainly of women, such as domestic workers in the Middle East. And women are disproportionally victims of human trafficking (Miller, 2008). 6. The proliferation of migration transition: more and more states have experienced migration transition; that is, traditional lands of emigration 11The 2005 report of the Geneva-based commission can be accessed at www.gcim.org.

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 MIGRATION, MOBILITY, AND HEALTH have become lands of immigration. States as diverse as Thailand, Turkey, Morocco, Greece, Italy, Spain, the Republic of South Korea, and Mexico have experienced transition during the Age of Migration (Miller, 2008). Table 1-1 summarizes the evolution of global migration between 1960 and 2005. There is mounting evidence that the worldwide financial and economic crisis of 2008-2009 has disproportionately adversely affected international migrants as has been the pattern in earlier economic crises such as in the mid-1970s. 12 Other measures of human mobility likewise attest to the growing significance of international migration. Table 1-2 lists the top 10 countries with the highest numbers of international migrants in 1990 and 2005. Spain viewed itself as a land of emigration and as a transit zone as late as 1990. Virtually all of its nearly five million migrants in 2005 had arrived illegally, were legalized, or arrived through family reunification measures. Table 1-3 indicates that international tourism is surging despite the War on Terrorism. Refugee and asylum-seeker flows, widespread human trafficking and smuggling, short-term highly skilled labor flows, student study abroad, and other forms of international mobility suggest that few human beings today are unaf - fected by international migration. In 2009, the Organisation for Economic Co- operation and Development (OECD) estimated that approximately five million people cross international borders each year to take up residency in a developed country. Thoughts About the Future of Migration and Development13 Usually understanding the past serves as the best guide to understanding the future. International migration played a central role in the shaping of the mod - ern, Westphalian world in which we still live. It is likely to continue forging and reforging states and societies in the future. International migration can foster development in both receiving and sending areas, as attested to by the U.S.-Swedish migratory relationship before 1914.14 High hopes were attached to the promise of international migration generating sustained socioeconomic and political development in the Asian and African hinterlands of West Europe in the 1960s and 1970s, but those hopes largely proved misplaced. Nevertheless, a new optimism has arisen over prospects for migration and development through well-managed bilateral and regional policies. This optimism 12 Postings on the effects of the ongoing crisis for international migrants can be found at www. age-of-migration.com. 13The following text comes from Miller (2008). 14 Hatton and Williamson (2005) observe that Sweden largely closed its development gap with Great Britain and other more advanced European states between 1860 and 1914 when about one-fifth of all Swedes emigrated to the New World and principally to the upper midwest of the United States.

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 INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD TABLE 1-1 Number of International Migrants by Region, 1960-2005 (in millions) Region 1960 1970 1980 1990 2000 2005 World 76 81 99 155 177 191 More developed regions 32 38 48 82 105 115 Less developed regions 43 43 52 73 72 75 Africa 9 10 14 16 17 17 Asia 29 28 32 50 50 53 Europe 14 19 22 49 58 64 Latin America & Caribbean 6 6 6 7 6 7 Northern America orthern 13 13 18 28 40 45 Oceania 2 3 4 5 5 5 NOTE: The UN defines migrants as persons who have lived outside their country of birth for 12 months or more. SOURCE: UNDESA (2006). TABLE 1-2 The 10 Countries with the Highest Number of International Migrants (in millions) Rank 1990 2005 1 United States of America 23.3 United States of America 38.4 2 Russian Federation 11.5 Russian Federation 12.1 3 India 7.4 India 10.1 4 Ukraine 7.1 Ukraine 6.8 5 Pakistan 6.6 France 6.5 6 Germany 5.9 Saudi Arabia 6.4 7 France 5.9 Canada 6.1 8 Saudi Arabia 4.7 India 5.7 9 Canada 4.3 United Kingdom 5.4 10 Australia 4.0 Spain 4.8 SOURCE: Based on data in UNDESA (2006) and reprinted from Koslowski (2008) with permission from the Center for Migration Studies. is linked to more precise understanding of the vast volume of migrant remittances to homelands. A number of scholars and policy makers have advocated temporary foreign worker admissions policies in OECD democracies as part of a circular migration strategy to promote mutually beneficial development in sending and receiving states. A certain skepticism about such advocacy appears in order. The historical track record of temporary foreign worker admissions policies in democratic settings can be termed checkered at best. Guestworker, seasonal

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 MIGRATION, MOBILITY, AND HEALTH TABLE 1-3 International Tourist Arrivals (in millions, ordered in 2006 ranking) Rank 1995 2000 2002 2003 2004 2005 2006 World 535.0 682.0 702.0 691.0 761.0 803.0 846.0 1 France 60.0 77.2 n/a 75.0 75.1 75.9 79.1 2 Spain 34.9 47.9 n/a 50.8 52.4 55.9 58.5 3 US 43.5 51.2 43.6 41.2 46.1 49.2 51.1 4 China 20.0 31.2 36.8 33.0 41.8 46.8 49.6 5 Italy 31.1 41.2 n/a 39.6 37.1 36.5 41.1 6 UK 23.5 25.2 n/a 24.7 27.7 28.0 30.7 7 Germany 14.8 19.0 n/a 18.4 20.1 21.5 23.6 8 Mexico 20.2 20.6 19.7 18.7 20.6 21.9 21.4 9 Austria 17.2 18.0 n/a 19.1 19.4 20.0 20.3 10 Russia n/a n/a n/a 20.4 19.9 19.9 20.2 11 Turkey 7.1 9.6 n/a 13.3 16.8 20.3 n/a SOURCE: Based on data in UNWTO (2005, 2006, 2007) and reprinted from Koslowski (2008) with permission from the Center for Migration Studies. worker, and bracero-style policies15 had problems and unintended consequences for quite well understood reasons. The Swiss reformed their seasonal worker policy in 1964 to allow those workers who worked five consecutive seasons to adjust to resident status under diplomatic pressure from Italy. The volume of sea - sonal foreign worker admissions also became controversial, leading to the divi - sive anti-Ueberfremdung16 campaigns of the 1970s which gave way to similarly unsuccessful referenda campaigns to abolish seasonal foreign worker policies as incompatible with human dignity in the 1990s. Swiss seasonal worker policy was not mismanaged. And as late as the 1973 to 1975 period, many seasonal worker permits were not renewed due to the recession, thereby enabling Switzerland to shift some of the costs of the recession to Italy. Similarly, German guestworker policies generally were well administered. But there was considerable political sympathy for legally admitted foreign 15The lexicon of international migration specialists is replete with terms derived from non-English languages. Guestworker derives from the German Gastarbeiter, a word coined after World War II to replace Fremdarbeiter, foreign worker, as many foreign workers had died and suffered deprivations under Nazi rule. Seasonal worker derives from the French saisonnier and the German Saisonarbeiter. It refers to foreign workers who are admitted for periods of less than one year and who are required to repatriate at the end of that circumscribed period. Bracero means strong-armed one in Spanish and, in the context of U.S.-Mexico migratory relations, refers to Mexican workers admitted to perform temporary services of labor in the United States from 1917 to 1921 and from 1942 to 1964. Tell - ingly the once obscure vocabulary of international migration specialists has become the lexicon of diplomacy in the Age of Migration. 16A term coined in Swiss German prior to World War I referring to the perceived threat of an exces - sive presence of foreigners.

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0 INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD workers by the 1970s. German courts blocked conservative efforts to enforce rota- tion after 1973 as incompatible with the Federal Republic’s legal engagements and responsibilities. This constituted an enormous victory for German postwar democracy that is too little appreciated. Bracero-policy history between Mexico and the United States does not appear to have yielded much evidence of fostering sustainable development in Mexico. U.S. recruitment of temporary Mexican foreign workers dates back to before World War I. Such recruitment helped set in motion large-scale unauthor- ized migration to the United States. Significantly more unauthorized Mexican workers were returned to Mexico than legally recruited during the 1942 to 1964 period. The United States unilaterally terminated the policy in a period of grow - ing consciousness and concern about civil rights and the effects temporary foreign worker admissions had upon American farm workers. The evolution of French seasonal foreign worker admissions after World War II somewhat resembled events in Switzerland. Admissions of seasonal workers mainly for agricultural employment crested at about 250,000 per year in 1968 but were steadily phased out afterward. Significant numbers of seasonal workers became so-called faux saissoniers (or false seasonal workers) and overstayed their visas. Many applied for the recurrent legalizations between 1972 and the 1980s. Seasonal foreign worker admissions continue today but in very small numbers. Since 1990, a new generation of temporary foreign worker admission poli - cies have emerged in Europe, especially in Southern Europe. The new policies are more narrow-gauged than policies during the guestworker era. The key issue is: Will their outcomes resemble those of the guestworker era? Advocates of circular migration policies take an optimistic view. Spain’s recent bilateral initiatives toward Black African states in Western Africa perhaps best exemplify the optimistic perspective. In return for coopera - tion with Spain and the EU on management of international migration, including prevention of illegal migration and human trafficking, as well as readmission of citizens illegally entering the European space, Spain will provide for job training and then admit trained and prepared foreign workers for time-bound employment in sectors lacking adequate labor supply such as agriculture. At first glance, such policies may appear constructive, even progressive. But almost by definition, the legal status of temporary foreign workers is contingent. Usually the foreign workers are tied, as it were, to a particular employer or indus - try. Of course, there is no incontrovertible way to measure need for additional foreign workers in a given industry, but especially in agriculture. Perceptions of need represent outcomes of political and legal battles usually pitting employers against unions. Usually, employers have their way even with governments of the left, which has been the case in Spain since 2004. It is important to point out that there are viable policy alternatives to the circular migration model. Spain could also admit more persons from West Africa with permanent alien resident status. Those Africans admitted would be free to

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 MIGRATION, MOBILITY, AND HEALTH work throughout Spain. Nothing would constrain these workers to become EU citizens but it would be a possibility. Such legally admitted permanent resident aliens would be free to travel back and forth to their homelands. But many cer- tainly would opt for naturalization. Herein lies the major advantage of increased admission of permanent resident aliens. Spain and Spaniards would have to accept the likely reality of settlement, giving Spanish society and government a strong incentive to foster immigrant integration. Historically, supposedly temporary foreign worker policies have resulted in significant settlement. But states and societies were unprepared for such unexpected outcomes leading to integration deficits and long-term integra - tion issues. Preliminary analysis of Spain’s temporary foreign worker admissions, the so-called contingents, suggests that the historic pattern of unexpected policy outcomes will continue. Several contingents served as ways to legalize aliens in irregular status rather than to recruit foreign workers from abroad. Perceived unfairness in the administration of the contingents has roiled Spain’s relations with Morocco and several other homelands whose governments feel that more of their citizens should be legally admitted under bilateral agreements. Spanish unions and employers often disagree on how large the authorized contingent should be, reminiscent of the annual “headaches” that Swiss cantonal and federal officials spoke of in the 1970s and 1980s. Further enlargement or deepening of the EU and of other regional integra - tion frameworks worldwide also merits consideration. Canada, the United States, and Mexico could emulate the history of regional integration in Europe. The key problem lies in the dissimilarity between the North American Free Trade Agree - ment (NAFTA) and the EU. NAFTA does not have a political project, unlike the European Community (EC) and now the EU. The Security and Prosperity Partnership (SPP)17 agreement announced by the three NAFTA heads of state in 2005 may suggest a move in that direction. However, within each region and globally one can readily discern a need for greater cooperation between more developed and lesser developed states to promote greater socioeconomic development. The history of European structural funds designed to promote a more even playing ground within the European space deserves careful scrutiny by the NAFTA partners. Unfortunately, most OECD member states have ducked negotiations over international migration and development issues. The pattern was set at the 1986 OECD-sponsored conference on the future of international migration. The U.S. delegation was instructed to avoid anything resembling North/South dialogue at 17The SPP pledged the three states to work more closely and cooperatively on border, international migration, trade, and international security issues, particularly prevention of terrorist attacks.

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 MIGRATION, MOBILITY, AND HEALTH without integrating within health and between other sectors of global society including health systems and services, occupational and labor health, security, economics and trade, agriculture and food management, and the environment. A process of creating more effective tools with the capacity to meet as yet undefined or emerging threats has become a cornerstone of international public health preparedness and response. Extending the process into the sphere of migra- tion health is strongly supported by empirical evidence, recurrent international experience, and projections of the importance of population growth and mobility for the future of global health. New Approaches for Migration and Disease Control It is apparent that human migration will continue to be an important com - ponent of global infectious disease distribution. Population migration, disparate health system environments, and gaps in disease prevalence will both continue and probably grow as components of international disease spread over the near and medium term. As migration expands, the need to plan and prepare to deal with the associated infectious and noninfectious disease consequences of popu - lation mobility will become interests of more nations and health authorities. Reflecting that growing interest, the health of migrants was the subject of recent EU discussions in Portugal and a resolution at the WHO World Health Assembly in 2008 (WHO, 2008). The convergence of the increasing need to address the issues and the expanding awareness of the importance of health related to global migration provide an opportunity to modernize and revise policies and programs that are no longer effective. Those revisions will require and benefit from the following undertakings: • An integrated approach to migration health threat to risk assess- ment, analysis, and interpretation. Global health policies will need to reflect the dynamics, diversity, and disparities that are associated with the demography of modern migration and population mobility. Threat to risk assessment practices need to be more complex and inclusive of outcome determinants rather than being based on administrative migrant class or disease lists. This risk management approach to meeting the disease challenges of migration will better direct resources where benefit can be expected and have the potential to reduce unnecessary practices in low- risk situations. This meets the intent of the International Health Regula - tions while adhering to standard population and public health principles. The United States has recently begun moves in this direction. Centers for Disease Control and Prevention (CDC) guidelines for the immigration medical examinations of foreign nationals have been amended to incor- porate more flexible, risk-based approaches based on epidemiological and

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 INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD other factors (CDC, 2008c). These changes provide increased capacity to immigration medical screening to be aligned with situations constituting a public health emergency of international concern that require notification to WHO according to the International Health Regulations. • Functional approach to borders and boundaries. The potential for international spread of infectious diseases in association with migration remains a component of a world that contains health disparities and is ever more linked through mobile populations. Political boundaries are increasingly less effective components of control programs and policies. Any new or modern approaches to migration health and infectious disease control will need to address that reality. Migration and population mobility globalize risks that have in the past frequently remained isolated. As high-speed travel provides the opportu- nity for larger numbers of people to move between health disparities, the concept of the global village increasingly extends to the health care sector. While serious acute events of international public health significance are rare, sustained high levels of migration do affect the epidemiology of sev- eral infections in those nations transiting or receiving migrants. This has effects on the clinical awareness of health service providers and the need to consider rarely encountered diseases. It also expands the demands for diagnostic and management capacities that historically have been limited in distribution or location. The globalization of risk resulting from the fading role of the national boundary will mean that the education and training of health care providers will need to focus more attention on the global aspects of migration health (Boulware et al., 2007). Health services and public health systems must support investigative capacities extending further into the health care deliv- ery sector to support clinical services and international public health. • Modeling migration health on other coordinated international actions. Individual national programs, particularly when they are directed toward threats and risks that originate beyond their areas of jurisdiction, may have some role in dealing with the secondary effects of those risks. In terms of primary prevention, these approaches will be predictably ineffective. Coordinated international efforts are now essential in any attempt to control diseases of global public health significance. Local and national activities must continue but as components of integrated multilateral miti- gation strategy. Migration health control activities could easily follow that pattern. National immigration and citizenship legislative and regulatory requirements make it unlikely that nations that require immigration health

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 MIGRATION, MOBILITY, AND HEALTH interventions will reduce or eliminate those requirements. Those policies and programs could be easily integrated into global strategies supporting improved migration-associated disease control (Cattacin and Chimienti, 2007). Immigration health screening, for example, when it is undertaken by those nations who require it for national legislative purposes, could be integrated into other global health activities. Currently, in excess of two million individuals undergo routine immigration medical evaluation annu- ally for resettlement. While limited to specific infections and certain migrants, the information is presently used only for national immigra - tion requirements. Supporting global tuberculosis activities is an obvi - ous example; the majority of nations who utilize immigration health screening have elements of tuberculosis screening in their programs. The aggregate use of this and similar data could be used in conjunc- tion with other global public health activities. Other potential activities include international collaborative longitudinal studies of migrant health outcomes. Such studies using standardized methodology and definitions could significantly improve knowledge regarding the outcome of chronic or latent infections in migrants. Conclusions Designed to prevent the introduction of a limited list of diseases of his - torical public health significance that arose beyond national boundaries, most immigration health activities play at best a minimal role in international disease control activities in the modern context. While required by some immigrant- receiving countries’ national legislation, they are often based on the historical quarantine-derived strategies of exclusion and isolation, principles that for the most part only represent population-based public health approaches in very limited circumstances. The world public health community remains challenged by a variety of disease threats, several of which are intimately associated with population mobility. Recent awareness of the implications of local disease events for global health has prompted the revision and reconsideration of some of the basic historical principles behind organized disease control (Cetron and Simone, 2004). Some of the migration-related aspects of that revised regulatory methodology originate from the same historical approaches to disease control and are subject to many of the same weaknesses that prompted the revision of the International Health Regulations in 2005. Migration in its modern mobility-derived context plays an increasingly important role in the global epidemiology of infectious diseases and that role will continue as long as disease disparities exist and populations link high-prevalence to low-prevalence regions through mobility.

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